Julie Standering's Minnesota Fastpitch Academy

Athlete's Name: *

Parent's Name: *

Clinic Name: *

Parent Email:

Clinic Location: *

Emergency Contact: *

Clinic Start Date: *

Emergency Phone: *

Athlete's Email:

Insurance Company: *

Athlete's Birthday: *

Policy Number: *

MM/DD/YYYY

Current Medications:

High School Graduation Year: *

Date of Last Tetanus Shot: *

Primary Position: *

MM/DD/YYYY

Secondary Position: *

Medical Conditions & Allergies:

I hereby authorize the staff of Julie Standering's Minnesota Fastpitch Academy, LLC. to act for me according to their best
judgment in any emergency requiring medial attention and I hereby waive and release Minnesota Fastpitch Academy, LLC.
from any and/or all liability for any injuries or illnesses incurred while at Camp or in transportation to a medical facility,
except for injury resulting directly from gross negligence or willful misconduct. I have no knowledge of any physical
impairment that would be affect by the above named camper's participation in the Camp program as outlined in the
brochure. I also understand the Camp retains the right to use for publicity and advertising purposes photographs of campers
taken at the Camp.

I understand and agree that some activities occurring as a part of or incidental to the Event may be of a hazardous nature and/or
include physical and/or strenuous activity. Understanding this, I state that I have no medical condition or impairment,
including the use of medication that might inhibit my active participation in the Event named above. In the case of an injury or
medical emergency, I authorize the staff or employees of Organization to render first aid and/or obtain whatever medical
treatment he/she deems necessary for my welfare. I further understand and agree that I will be financially responsible for all
charges and fees incurred in the rendering of said treatment regardless of whether my medical insurance would cover such
charges and fees.

Parent/Legal Guardian Name:
*

Waiver Release Agreement: *

I agree to the terms and conditions of this release.

Please complete this Waiver Form prior to attending a Minnesota Fastpitch Academy
event. All fields marked with a * are required.

Minnesota Fastpitch Academy
899 3rd St. SW Suite 6
New Brighton, MN 55112